Zero separation: infant and family-centred developmental care in times of COVID-19

Abstract

Ever since its initiation by the European Foundation for the Care of Newborn Infants (EFCNI) more than 10 years ago, World Prematurity Day on November 17 has become a global movement to raise awareness for preterm birth and its consequences. More than one in ten babies are born preterm every year, and numbers are still increasing worldwide. The immediate and long- term health effects are severe; preterm birth is one of the leading causes of neonatal death.1,2 World Prematurity Day 2021 highlights the specific challenges that babies born too soon and their families have been facing during the still ongoing COVID-19 pandemic. For almost 2 years now, societies and health systems worldwide have been disrupted. Although the focus has rightly been on managing the COVID-19 crisis and its fallout, pandemic-related restrictions have also affected quality of care, including the application of an evidence-based infant and family-centred developmental care approach. 3,4 Implemented restrictions have put additional pressure on the already vulnerable group of newborn babies and their families, with the full effect of the long-term consequences yet to be seen. In contrast to international agreements, such as the 2030 Development Agenda5 or the UN Convention on the Rights of the Child,6 which underline the right to health and the right of children to be close to their parents, separation policies have been implemented in many neonatal intensive care units (NICUs) across countries. Although infection control measures were necessary to manage the emergency situation, the pace and blanket coverage of these measures applied also to parents of vulnerable infants, with immediate implications for child growth and development, and for the family as a whole.4,7,8 When the pandemic hit, we grew increasingly con - cerned about the impact on the provision of care to preterm babies, and sick and low birthweight infants in NICUs. Parents having inadequate access to their child had been voiced as a concern by several of the parent organisations in our network. Under the umbrella of the Global Alliance of Newborn Care (GLANCE), coordinated by EFCNI, we formed an international and interdisciplinary expert group, the EFCNI COVID-19 Zero Separation Collaborative Group (appendix), to conduct a global online survey of parents’ experiences with regard to the disruptions on different elements of infant and family- centred developmental care. Parents of newborn babies receiving special or intensive care shared their experiences regarding topics of prenatal care, parental access, infant nutrition and breastfeeding, health communication, and mental health. Overall, we collected responses from more than 2100 participants in 56 countries. 4,9 The results of the survey are alarming and have confirmed anecdotal evidence shared by many parents in the EFCNI and GLANCE network. More than 40% of all respondents were not allowed to be accompanied by a support person during prenatal appointments, and more than half even reported that they were not permitted to have a support person present during birth, leaving them without any emotional, informational, and practical support. Furthermore, presence with the newborn baby and skin- to-skin care were heavily restricted in the respective NICUs. One (21%) in five participants responded that Published Online November 16, 2021 https://doi.org/10.1016/ S2352-4642(21)00340-0 For more on World Prematurity Day see https://www.efcni.org/ activities/campaigns/wpd/ See Online for appendix staticnak1983/iStock 1,23,4564,7,84,9 Comment8 www.thelancet.com/child-adolescent Vol 6 January 2022 there was no parental access to the hospitalised newborn baby. The differential treatment experienced by mothers and their partners was astonishing—almost three quarters of the participants indicated that the mother was allowed to be present with the newborn baby in the NICU, but only slightly more than half answered that the father or partner was allowed access. Breastfeeding support was mostly maintained according to the responses to our survey, but less than one in five respondents still answered that they were not encouraged to breastfeed. In particular, communication between health-care pro - fessionals and parents, health information, and mental health support were largely inadequate during the first year of the pandemic. One third of respondents were lacking information on how to protect themselves and their child from COVID-19 transmission during the hospital stay and at discharge, and a large majority (75%) were worried because of the COVID-19 situation during pregnancy and after birth, adding additional stress in an already challenging situation. Overall, the results show country-specific differences, which also depend on the extent of COVID-19 related restrictions (eg, social distancing and lockdown).4,9 In view of the concerning nature of this feedback, we call for policy-makers, public health experts and health-care professionals to take immediate action to achieve zero separation and infant and family-centred developmental care.9 Although an increasing number of neonatal units worldwide already adopt this care approach, policies need to be developed to ensure such care is maintained in emergency situations. A safe environment and respectful and supportive care during pregnancy, labour, and birth should be guaranteed, and support people should be allowed during prenatal appointments and birth. Every baby born too soon, too small, or too sick should receive high-quality care in all settings for the best start in life. Health providers should value, include, and empower parents as key caregivers of their newborns at all times. Hospitals should establish zero separation and family-inclusive policies, and ensure parental presence to enable immediate skin-to-skin and Kangaroo Mother Care, and family–infant bonding. Health providers should also prioritise breast milk and encourage breastfeeding when possible, emphasising the benefits of adequate infant nutrition for all newborn babies. There should also be adequate provision of health information and continuous and respectful communication between health-care professionals and parents. Parents and families in need should be offered access to and receive mental health support. Worldwide, a holistic approach to infant and family- centred developmental care needs to be strengthened urgently. This is even more important in times of crisis, in which restrictions are quickly implemented. The reports from our networks strengthen our position as we continue to advocate for a zero-separation policy of infants from their parents and caregivers. Infant and family-centred developmental care must be reinstalled where it was discontinued, it must be promoted where it was questioned, and it must be protected where it was restricted. Zero separation must be realised to give all newborn babies the best possible start in life. SM is the co-founder and chairwoman of the European Foundation for the Care of Newborn Infants (EFCNI). The survey has been independently conducted by the members of the EFCNI COVID-19 Zero Separation Collaborative Group, in cooperation with representatives of national parent organisations and the professional healthcare societies: Council of International Neonatal Nurses, European Society for Paediatric Research, Newborn Individualized Developmental Care and Assessment Program, and Union of European Neonatal & Perinatal Societies. EFCNI has received an earmarked donation by Novartis Pharma AG in support of this project. A full list of the EFCNI COVID-19 Zero Separation Collaborative Group members is in the appendix. Johanna Kostenzer, Luc J I Zimmermann, *Silke Mader, on behalf of the EFCNI COVID-19 Zero Separation Collaborative Group s.maderoffice@efcni.org European Foundation for the Care of Newborn Infants, 81379 Munich, Germany (JK, LJIZ, SM) 1 Althabe F, Howson CP, Kinney M, Lawn J, WHO. Born too soon: the global action report on preterm birth. 2012. www.who.int/pmnch/media/ news/2012/201204%5Fborntoosoon-report.pdf (accessed Oct 29, 2021). 2 WHO. Preterm birth. 2018. www.who.int/news-room/fact-sheets/detail/ preterm-birth (accessed Oct 29, 2021). 3 Rao SPN, Minckas N, Medvedev MM, Gathara D, et al. Small and sick newborn care during the COVID-19 pandemic: global survey and thematic analysis of healthcare providers’ voices and experiences. BMJ GloB Health 2021; 6: e004347. 4 Kostenzer J, Hoffmann J, von Rosenstiel-Pulver C, et al. Neonatal care during the COVID-19 pandemic – a global survey of parents’ experiences regarding infant and family-centred developmental care. EClinicalMedicine 2021; 39: 101056. 5 UN General Assembly. Transforming our world: the 2030 agenda for sustainable development. 2015. https://sdgs.un.org/2030agenda (accessed Oct 29, 2021). 6 UN Commission on Human Rights. Convention on the Rights of the Child. 1990. https://www.ohchr.org/Documents/ProfessionalInterest/crc.pdf (accessed Oct 29, 2021). 7 Muniraman H, Ali M, Cawley P, et al. Parental perceptions of the impact of neonatal unit visitation policies during COVID-19 pandemic. BMJ Paediatr Open 2020; 4: e000899. 8 van Veenendaal NR, Deierl A, Bacchini F, O’Brien K, Franck LS, The International Steering Committee for Family Integrated Care. Supporting parents as essential care partners in neonatal units during the SARS-CoV-2 pandemic. Acta Paediatr 2021; 110: 2008–22. 9 EFCNI, Kostenzer J, von Rosenstiel-Pulver C, et al. Zero separation. Together for better care! Infant and family-centred developmental care in times of COVID-19—A global survey of parents’ experiences project report. 2021. https://www.glance-network.org/covid-19/survey (accessed Nov 11, 2021)